narrator: baby cuevas, only minutes old, and yet factors that will influence his health are already set into motion. in the years that follow, what other influences will shape his existence? will he lead his life fully as a healthy, productive human being? or will he fall short of his family's dreams at this moment? and what will make the difference?

health is not a single state of being. it is a combination of factors which, over time, shape and mold the life of a human being. we have various definitions of health which certainly, in modern times, we think of as not just the absence of disease but... a positive health status, you know-- a well being and ability to be active and productive in one's life. in its simplest form, being healthy is feeling that there are few physical or emotional impediments to your doing the kinds of things with your life that you'd like to. it's not so much a biological state as it is a state of mind. there are many people who are suffering chronic illnesses

who are supremely healthy because they are able to maintain their creativity, and their vivacity in the face of a condition that, to other people, just sends them for a loop. being healthy is, healthy first with the mind, having a sense of balance in life. also, i would say, health for me would be eating well, being able to exercise, and being able to be fully active in life. working is a part of health, i think, for many americans, and having a job that's productive and fulfilling is quite important in this perspective. the world health organization describes health as a state of social, physical, and economic well being. i mean, they take in everything, and they're quite right, that if you don't have economic strength

and the necessary wherewithal, you'll probably not do well in the world. you'll probably suffer in various ways. i think certainly people that are the highest risk of poor health are those with poor resources, poor financial resources, poor educational resources, because they may not make good judgments or have access to health care when it's very essential, or when it's crucial in prevention of progression of an illness. david bennett: but for many people in the world, their demands in terms of health are mu more modest. the people who face hunger, who face the threat of disease constantly, for them, survival is really health. to see the very quiet, subtle way in which communities can pull together is really quite remarkable. if we have that very broad definition, then everything becomes health. if we look only at certain narrowly defined diseases,

we miss somehow the whole interaction that makes up the human being. the whole interaction that makes up the health of a human being begins with a genetic map. dean hamer: dna is like a blueprint that determines not t only our physical bodie, but also, at least in part, our brains. and our brains, of course, are what control our behavior, and so, although it surprises some people, our genes also play a role in the way we think about things, the way we feel about things, and the things that we do. so we have 100,000 genes, and all of us have to have two copies of each gene, one from each parent. each time they're being transmitted from parent to offspring, the genes have to be copied. and the copying system isn't perfect, so little mistakes are made, or changes, and most of them are irrelevant. but over time, we have in the population

for any given gene, variance. in fact, my dna, and your dna, and somebody else's dna is 99.9% the same. but there's about one base out of 1000 that's different. so michael jackson's dna might read "a," and michael jordan's dna might read "g," and michelangelo's dna might read "c," and so on and so forth. and surprisingly those very few differences, that one out of 1000, is enough to make all the differences in the way we look, blue eyes or green eyes, our skin color, our height, as well as in some of our behavioral traits. sometimes people are surprised that such a tiny bit of difference-- .1% can make such a big difference in who we are. but remember that our dna and chimpanzee dna is only 1% different, and obviously we're a lot different than chimps. genes are not all that matter in terms of human health. they offer possibilities and predictions,

but not certainty. paul mchugh: genes are just dna. they aren't destiny. some aspect of our life experience, what we choose and what we do, how we form our character given our constitution, is what ultimately makes us the kinds of people we are. the idea that somehow or another we're destined because of genes to be a particular kind of person is not only not true in human life, but it's also, of course, not true in anything in life. the phenotype that's expressed in any organism is in part what their genetic nature is, but it's also a part of what kind of an environment and life they live-- the nurture they have. so you can be genetically susceptible, but never exposed. but i think there's a public perception that the environment-- i mean smog, pesticides, water pollution, hair spray, you name it--

that these things are important causes of disease, and the reality is, they're not. there are a few biggies. there's cigarette smoke; there's asbestos... which is pretty much a problem of the past. and then, it's a pretty short list. the rest of the causes of disease are-- if they're not infectious-- are inside us. but often, the conditions in which one lives play a critical role in the ability to maintain good health, clearly, in most communities a level of development which has benefited many people, but left others behind. so one sees large slum areas of marginalized people, with people living under very poor conditions around the big cities. i saw it in china when i went there with my family in 1982. the farther away from beijing we went,

the more "third world" china was. it looked like uganda, almost. you can find it in skid row in this city. i set up a free clinic in skid row with the los angeles catholic workers. we saw a lot of people coming in from mexico, recent immigrants with their children, who had some of the same disease problems. and their challenge is really to get the type of health care, preventive care, and treatment for illness that can be relatively difficult to get, and can be relatively expensive. peter clarke: and these people are caught in a vise-- where rising rents, the high cost of good food, the need for medications and health care for children or themselves-- these are crushing factors. and the first thing that gets sacrificed in that trio is good eating, because it's the thing

that you can sort of get along without as long as you have enough calories. marc shiffman: the indigent population faces day to day challenges that are formidable, from the moment they wake up, until the moment they go to bed. and so what we-- you and i-- may take for granted in our day to day running errands and doing this and that, and getting here and there, and going to appointments, and meals and taking care of family, and whatever other responsibilities most of which we may consider mundane-- these are all the issues that impact adversely on their health, because they can't all be sorted out properly. and so in every way, shape and form, the lifestyle impacts adversely on their health. the effects of poverty on health appear to strike hardest at those who are at either end of the age continuum-- the very young and the very old. michael bryant: the concept of primary and preventative health care maintenance--

that is what we should be about, because if we can intervene early, then we are able to... to try and prevent some of the untoward effects that kids will realize as they grow older, as they become adults. you know, as we look to-- and there's been lots of rhetoric, political rhetoric, about universal healthcare, and who should get that... should that be extended to the entire population? i think a good place to start is with the children. my god, we should be trying to take care of our children. you know, the issues about adults are very complex, and, you know-- many adults-- the reasons they're unhealthy are because of things they do themselves or do to themselves. but kids are incredibly vulnerable, and i would think it would have to be a priority of ours to try and protect and ensure their health. marc shiffman: there are too many people out there... who are senior citizens-- fixed low income.

medicare is their only insurance, and as they get older, as they get sicker, as they need more medications, they are having to make difficult choices. - hi. how are you doing today? - hello, mrs. phillips. - how are you? - it's good to see you. my social worker spends some time almost every day calling up drug companies, filling out forms to get special dispensations for medications. people break pills in half to stretch them, or they just go without because they've got a food bill, they've got an electrical bill, they've got a mortgage to pay, a rent-- whatever it is. they make choices. this happens more in senior citizens. the young, poor population, and this probably is more single mothers that we see, trying to raise children-- some working, some not working, also are faced with choices. and oftentimes because their lives are so hectic,

raising the kids and perhaps working, whatever else they're doing, they do come in to see us late. the health of any nation is closely linked to the health of its people, the productivity of its workforce, the health of future generations-- its survival depends on it. most countries have ministers of health, or public health services whose challenge is to protect the health of society as a whole. looking at all of the factors that influence health in entire populations: a commitment to really put primacy on prevention rather than cure; a commitment to social justice, and to looking at all societal factors and environmental factors that influence health, behavioral factors, as well as factors relating to the healthcare system. in the united states, the concern we have about the public health system is that we have the adequate infrastructure and support

for the government aspects of public health that protect us, keep our water supplies safe, that protect us against outbreaks of new infections or new diseases, that assure that we have the best policies to protect the public health at the state and local level as well as the federal level, that we pay enough attention to that infrastructure that we can protect ourselves as a society. but for public health officials, health is no longer just a local or national concern, it has global dimensions. james curran: well, you know, certainly during my lifetime, the world has shrunken. i guess it's the same size as it's always been, but the airplanes take us as well as microbes and organisms and animals rapidly between countries and between continents. this is not the "guns, germs, and steel" environment

of-- represented in the book, but rather it's an environment where there's very rapid transmission of ideas, of concepts, and of risks. for example, if it's true that aids first arose somewhere in central africa, it would have been-- the world would have been a lot better off if that part of africa had had a better surveillance system and could have discovered this problem a year or more earlier than they did. that's just one example. this inter-relatedness of the world community was instrumental to the formation of the pan american health organization... even though the year was 1902. the intention was to provide a forum in which the countries could tell each other about what diseases were a problem, and agree on approaches that would allow for the control of the diseases-- these diseases-- without impeding trade. in those times, of course, was largely by ship. in 1948, the concept expanded

with the formation of the world health organization, and six regional offices that included paho. some of its efforts are focused toward the eradication of single diseases like polio, using thsalk d th. david bennett: with these tools, particularly the oral vaccine which is very-- relatively easy to use, and very effective, we felt we could undertake eradication of polio from the americas, embarked upon that, and then by 1991, had seen the last case of wild polio virus in peru-- the last case for the entire americas. in 1988... i think as a result of some pressure from the americas, the world health assembly agreed that the world would take on the effort to eradicate polio. we still have polio in the indian subcontinent, in parts of the middle east, and across much of central and eastern africa,

so the challenge is pretty big. we are making headway; the immunization levels are going up. national immunization days-- polio days are being held around the world. it is very, very important, particularly for people in the united states and other relatively wealthy countries to understand, that this is one small boat. and we may be in the more affluent part of the boat, but we're still in the same boat, and 's in our interest to help everybody understand their health and deal with their health problems, especially the infectious disease problems. how do public health experts measure the health of a group of people? the two statistics most often cited are life expectancy, and infant mortality. life expectancy is how long we think we're going to live. life span is how long we're actually able to live, and that's a species specific kind of thing. so, for humans, the maximum amount of time we can live

is about 120 years. if you live a good smoke-free life, keep your normal weight, exercise, your chances of living longer and living healthier are so much greater now than they were for our counterparts 100 years ago. the average life expectancy of an american in 1900 was just over 40 years. now it's close to 80. this has been a tremendous public health achievement. and if you look, most of those years of gain that have occurred over this century haven't necessarily occurred because of very technologic medical advances. they've occurred because of very, very simple public health measures, whether it's sanitation, or whether it's refrigeration, or whether it's handwashing and the availability of soap, or whether it's vaccines, those are, by and large, what have driven the improvements in life expectancy over this century.

and in particular, in the area of infectious diseases. we have to realize in 1900 that tuberculosis was the single leading cause of death in the unitedtates, and, at the close of this century, the total number of deaths from tuberculosis in this country are under 1500, probably closer to 1000 people a year. we have a really brilliant saying in geriatrics, which is, "the longer you live, the longer you live." and what that means is, as you age, your life expectancy actually increases. so if you've made it past childhood, you can expect to live to young adulthood, and if you make it past young adulthood, you can expect to live into old age. and as you live into old age, you can expect to live longer. if you're a healthy 85-year-old, you can easily expect to live another seven years. the gains in life expectancy that have been achieved in the industrialized world are only partially replicated in developing countries.

certainly there have been major gains in latin america, major gains in china, but there are a lot of threats to the developing world-- threats of continued infectious disease, threats of aids, threats caused by the incursion of smoking in the developing world where smoking-related illnesses in the next few decades will become the leading cause of death in the world, and threats from overpopulation and the incursions upon the environment. most of the deaths that occur, occur in children under the age of 5 years. if you look at what the leading causes of infectious disease deaths are in developing countries, they're things like acute respiratory diseases, particularly pneumonia in children. measles is still a major killer. tuberculosis is clearly a major killer. malaria-- we have the vaccines, we have the antibiotics,

we have the oral rehydration therapy. the problem is that we simply don't get these technologies to where they're needed. in looking at the two principal measures that are used to evaluate public health, how does the united states rank in comparison to other nations? the united states is in the bottom quartile, in the bottom 25% in most of these indicators compared to the other industrialized countries. and it's relative ranking over the last 30 years has declined, so we have gotten worse relative to the other countries. we're improving-- everybody's improving. we're just improving at a slower rate than these other countries. the difficulty is... that most of what we do... now, affects quality of life, not length of life, and we spend a lot of our money on that particular thing. if you have a patient with angina,

with severe chest pain every time they take a couple of steps because of coronary disease, and you can put that person back on the stre, so to speak, functioning normally and working, that doesn't show up in the statistics. most of the people who have an angioplasty have a kind of lesion in which repair of the abnormality does not extend life, but it relieves symptoms. and so with many of the things that we do, say for vision-- something as simple as cataracts, and the implantation of artificial lenses-- that's revolutionized the lives of older people who were virtually blind because of cataracts. what's that worth? that's worth a lot, and it doesn't extend life expectancy, or at least if it does, to a very minimum degree, so i think it's quite unfair to judge a system on the basis solely of length of life and infant mortality.

those are reasonable criteria... but you have to weigh in quality of life in a major, major way. but other factors also seem to influence the statistical profile of health in the united states. life expectancy has gone up, but infant mortality doesn't come down. and part of that is due to the fact that people are living under circumstances that don't favor healthy pregnancies and healthy early childhood, and where they don't get the type of health care that they need because they can't afford it. and in rural communities, it's not available. gerard anderson: of the industrialized countries, we and mexico and turkey are the three countries that have large numbers of uninsured. and so you know that those people are in serious trouble when they get sick, and they are responsible not due to their own fault, but they are the cause for a lot of our higher infant mortality rates, our low life expectancy, and whatever.

every person in america needs to have access to excellent health care and health services. and there are several barriers from that happening. some are financial, and some are system-wide, and these seem to be increasing rather than decreasing at a time when our nation has more wealth and more prosperity than ever. that's deeply disturbing. as a physician, i see... the system beginning to blame itself, and blame each other. today, the hmo's are the problem. tomorrow the government will be the problem. the next day, maybe it'll be the doctors, or it'll be the patients themselves for failing to interpret and navigate the system. this is a dangerous trend. the second thing is we have more discrepancy in high incomes

and low incomes in the united states as compared to most of the other countries. they have a much better income support. peter clarke: every indicator... of mortality and morbidity, shows a straight line income function. the lower your income, the quicker your death, and the more serious the burdens you're carrying for chronic conditions. clearly, there are steps that governments can take to improve the health of their citizens. but even more immediate, and more controllable on a personal level, are those steps we can take for ourselves. the key understanding is that what i do affects my health at least as much, maybe more, than anything that can be done to me in a hospital, etc., and that i need to start taking care of my health right from a very young age, as soon as i can have that understanding.

i think that is a key message, and there the challenge becomes, with young people, who tend to think they're immortal, etc., haven't had some of these life experiences, just to get them to understand that some of the decisions they're making-- young or not-- are key, and they're going to affect them for the rest of their lives. marc shiffman: our number one overriding societal impact on health is still drugs and substance abuse. illicit drugs, alcohol... are one and two. and obviously those spawn a violent culture, whether it's domestic abuse, whether it's street violence, but it all goes back to the substance abuse. there's no getting around that. that is, without a doubt, the single most important impact on what we see. i think when people think of behaviors, they think more along the lines of chronic diseases,

whether it's exercise, or whether it's smoking, or whether it's alcohol, i think people readily recognize that there's a significant behavioral aspect to who the risk groups are for chronic diseases. i don't think that there's as great a perception that behavior also plays a very important role in infectious diseases, whether it's sexual behavior and its relationship to hiv, whether or not it's the foods you eat and how you cook them, whether it's behavior surrounding antibiotic seeking and taking antibiotics, or whether or not it's the types of activities and whether or not you want to use insect repellents when you decide to go out for a hike on a nice summer day. behaviors are critical to not only chronic diseases, but also to infectious diseases. to be healthy, people need to know about health.

you need to be your own consumer. you need to read about health, and how to stay healthy. you need to learn about it, and then you need to abide by certain principles. don't smoke. absolutely don't smoke. maintain your ideal weight... get plenty of exercise... have a trusted healthcare provider who's knowledgeable, and know a lot yourself. ask questions. don't distrust the medical system, but be a consumer who is well informed.

"the human condition" is a 26 part series about health and wellness. for more information on this program, and accompanying materials, call: or, visit us online at: on this program, and accompanying materials, call: woman: i've had a long marriage, jobs, kids. then the grandchildren came along. it took hard work and a lot of planning. but one thing i didn't plan on was macular degeneration. it's stealing my eyesight and my independence, and the disease will reach

epidemic proportions as my children age. call 1-800-437-2423 for free information from macular degeneration research. 1-800-437-2423.

a group of french doctors working for the red cross sought permission to provide aid to the 100,000 refugees in biafra who were suffering from famine and disease. but because these refugees were on the "wrong" side of the government in a civil war, the red cross said "no." the doctors resigned their post and started what was to become "doctors without borders," an organization committed to serving all populations in need, regardless of politics or national borders. at the same time, a hemisphere and continent away, the people of venice, california were demanding health care for those who could not afford to pay for it. a group of concerned citizens, working with two local doctors, secured the loan of a dental office at night, and started a volunteer clinic. from these humble beginnings emerged the venice family clinic,

the largest fr clinic in the united states. this is the story of two organizations and the people they serve... in the name of health, and humanity. suraj achar had only recently opened his family practice

when he left for six months to help somali refugees who were entering kenya near the border with somalia and ethiopia. suraj achar: when we landed our plane on the dirt field, you couldn't see anything green for tens of miles all around and, unfortunately, when i landed, i recognized the suffering the people were encountering there. the children were severely malnourished. i could see it from their faces and their bellies, and the animals were dying actually in front of me. some of the animals were laying on the ground suffering because they had nothing to eat, and no water. teams of volunteers from 45 nations serve with "doctors without borders," wherever and whenever the need arises. i was the only doctor in the team because we're a nutrition-based team. we had up to four nurses. we had logisticians who came from diverse backgrounds: we had a computer engineer from spain, a stockbroker who worked in the trading houses in toronto;

a fireman from france; and everybody had jobs to do. and they were trained with "doctors without borders," or at least debriefed, before they came onto the mission and trained with people who were leaving the mission. the somalis did not instantly accept or trust the new team. suraj achar: to survive in the desert, with the wars, and the famines and the catastrophes that somali people have survived, makes them a little tough skinned. and it was difficult for us, the whole team-- not just myself-- to earn their respect and achieve their trust. fortunately we were there for such a long time, and we were doing such intensive work with them on a day to day basis-- especially with the children and the mothers who were most hit by severe malnutrition-- that they grew to trust us over time, and would bring us their most severe cases. the incidence of malnutrition, particularly among the children, was alarming.

and with severe malnutrition, the mortality of this disease, depending on the variation of protein energy malnutrition that we see, can be as high as 30 to 50%. usually the children die from routine infections like diarrhea or pneumonia. in fact, pneumonia is the most common cause of death. children who are severely malnourished appear anorexic. they do not want to eat. they're often very depressed. their heads are low. they stop talking. they stop walking, and they're severely dehydrated and suffering from infectious diseases. perhaps the most extreme case of malnutrition the team witnessed was annis-- a tiny wisp of a girl, two and a half years old. annis is just skin and bones and a head. and i looked at her, and i looked at the weight, and i asked the mother how old she is and the mother told me. and i said, "it's not possible." so i took annis myself back to weigh. i saw the scale, it said 4.2 kilos,

took annis off, measured her height, put her back on the scale. i still couldn't believe it. it was amazing to me that annis was still alive. the highest mortality for children so severely malnourished occurs in the first few days. if you overfeed these kids they will die from electrolyte changes in their body. so you have to be very careful. we immediately started her on a rehydration program as well as high energy milk and antibiotics for her infections. and as she started getting better, we started her on soya bean protein mix. and i would come by daily to check on annis' progress. what he discovered was that annis' mother was feeding her daughter's food to her other children, and even eating some of it herself. and the food was very basic. it included high energy protein shakes that were like milk, plus a soya bean porridge. and we used this, and it had a variety of nutrients in it--

full range of amino acids which are the building blocks for our proteins in our body. i would have to go and get more food to give to annis myself, and i would individually feed annis. and i asked mother why would she not give any food for annis. and mother said she had already given up on annis, that there was no chance that annis was going to survive and that her older children were very important to her and she wanted to help them as much as she could. and over time, in our program, annis' mother began to trust us. and as we were feeding annis, annis' mother would also feed annis. it was amazing when she would raise her head, and look up and smile eventually, and eventually even almost start trying to walk. i would carry her around on rounds, and to see her thrive and survive when her mother was so sure that she would never do so, was probably one of the more beautiful experiences that i had there. but as well as the program seemed to be progressing,

the challenges were just beginning. about six weeks into my stay i was called to come to the intensive care feeding center where we keep our most critical cases... at 4:45 or 5:00 in the morning, very early. and we rushed over there in the dark in our four-wheel-drive car, we found in the tent where we keep our children with tuberculosis, was one of the mothers lying prostrate on the floor in a pool of diarrhea and vomitus. we assessed her quickly and found she had almost no pulse that we could palpate. we could barely detect a blood pressure, and she was almost comatose. she would barely respond to pain. we then immediately started her on iv fluids. within 15 minutes we'd given her seven liters of fluid to replace some of the losses, just some of the losses that she had encountered over the night when she had started her diarrhea.

and we noted the water that was coming out-- the stool quality was very different than usual. it looks almost like rice and water mixed together. and we were astounded by this because we knew that this probably meant cholera. samples were sent to nairobi for analysis, and within a few days the diagnosis was confirmed. it was indeed cholera. at that point, the lives of the "doctors without borders" team and their mission, changed dramatically. iv bags of fluid, antibiotics, and chemicals to purify the water and prevent the spread of cholera were airlifted to the site. one of the most devastating problems with cholera is it can go quickly amongst patients who are immuno-suppressed, like our children with malnutrition, and it can cause high, high mortality in this population. so we quickly had to isolate the kids and adults who had cholera. we built a center with beds

and iv bags hanging from the roof for the patients who were suffering that were adults. we removed the children with tuberculosis from our isolation tent, and put our children with cholera in this tent. then we built a chlorine bath all around. we burned all their clothes-- anything that potentially could have cholera, we burned it. we built a special latrine for their waste. and we tried to isolate them as much as possible while, at the same time, providing very intensive care for their dehydration, which is the critical problem in cholera. it's a disease that comes on within a few days of incubation, and may only last a few days. but within those three days, you can lose half your weight in diarrhea, and critically need support. iv fluids, oral rehydration fluids-- all of that plus the antibiotics that the cholera would be sensitive to. before the cholera outbreak, only a small percentage of the children with severe malnutrition died.

once the cholera hit, that figure rose. it's very difficult to fight cholera. and these children would have as many as 50 episodes of diarrhea in a 12 hour period. losing so much water, it's ve hard to keep up. often times i would go to lunch and come back and a new child would just fall ill during the lunchtime with diarrhea, and would pass away within hours. children were brought to us and would just pass away within five minutes of arriving at our center. so we had some very rapid demises. and it was very difficult as a physician. for a while, my nurses, the local staff, were wondering, am i really a doctor?-- because we were having so many deaths. the epidemic lasted about a month, infecting between 500 and 1000 adults and children. others probably were asymptomatic and carried the bacteria as well. the total number of deaths in the children

was probably in the teens. but still, for us, it was devastating to watch a child expire. the death of a child generated a whole new set of challenges. the somali people are moslem, and they're very particular about their ceremonies and their burial ceremonies. but unfortunately, the remains of the children were very infectious and we had to isolate them. so we came up with a compromise. we would clean the child after the child expired and then put them in a body bag. and we'd hand them to the families and they would bury them in the body bag which was somewhat of a protection for the community. at times, the situation was frustrating for dr. achar and his team, knowing that they really couldn't do everything they were trained to do. when the children became the most severely ill and we didn't have a way to manage them, to measure their electrolytes, to measure their fluid balance in their body most accurately,

to culture their infectious diseases most accurately, to measure their blood count to see how anemic they were and to potentially get the medicines that weren't available, or diagnostic tests that weren't available, and then to watch these children- some of these children pass away... that's probably the most difficult experience for any physician from the west to work in-- the situation like we had in africa. but as the cholera epidemic waned, and attention once again focused on the malnutrition scourge they were sent to attack, the good they were doing came full circle. i remember doing an evaluation on two children-- one who was four, two girls, and one was six. coming from a town in ethiopia, very nearby, they would walk 10 to 15 kilometers every day with no shoes on through the desert. the temperature was about 110 to 120 in the shade during their walk.

they would come, and they would get their nutrition in the morning, and then they would stay sitting outside in the sun for the feeding that would happen in the afternoon. and then they would go home and... on saturdays we would give them a packet of food for sunday. well, after evaluating them and finding out that they had no medical complications that would necessitate medical care, i was about to discharge them, and i asked them, "what is it like on sunday for you?" and these two girls said to me that their food is distributed amongst the family. and because the family doesn't eat during the week, the family eats the food that they bring home on sunday. but they were very happy coming on the other days where they would get the soybean porridge. and i asked the older child if i were to discharge them from our program, would there be a way for them to get food in ethiopia? and she looked at me and said, "probably not," through a translator--

that there was no option for them outside of our program. after hearing the story, of course i found some medical excuse to keep them in our program and continue them there. but being able to help children like that who have nowhere else to turn, was just a great privilege, just a beautiful experience. the health needs of people who live in venice, california may seem a far cry from the health needs of somali refugees. but there is a common denominator: people in need, without adequate resources to maintain their health. it's a few minutes before 9:00, and already, activity at the venice family clinic is in high gear. elizabeth benson forer: our mission is to provide comprehensive primary healthcare that's affordable, accessible and compassionate for people who have no other access to care. we truly are unique in that

we're not seeking business with money attached. we're seeking people with no health insurance and low incomes. ana zeledón friendly: the majority of our patients are hispanic, and many of them monolingual, so all of our staff members are bilingual in english and spanish. and they're able to provide the services, also in a culturally sensitive manner. and we do have also a large immigrant population from russia. susan fleischman: most of them are older people in their 50s and 60s, but they seem older than that. they've come to this country mostly as economic refugees. most of them have almost no english skills, and they are very, very sick. they have terrible hypertension, lots and lots of heart disease and cardiovascular disease and terrible depression, as well. and they have a very difficult time assimilating to life here.

the clinic also serves several thousand homeless people. ana zeledón friendly: we have a special program where our homeless are able toalk in on a daily basis, and we have slots available for them so we can see them right away. susan fleischman: i think most patients are nervous the first time they come here. they clearly don't know what to expect. i don't know how they've heard about us, maybe from a friend, from a family member. i think they're nervous about the quality of care. i think they're nervous language-wise... "will there be someone there who speaks and understands my language?" they're worried about whether we're going to call immigration. they're worried about whether coming here will affect their children's ability to become u.s. citizens, so there's a whole host of worries. elizabeth benson forer: we try to make it so that it's easy for them to get care. it's as simple as really writing down their name. it's a self-declaration. someone can say, "i'm jose, and this is how much i earn. i earn $14,000 a year," and that's it.

some of our patients want to show us and want to provide proof. but, for the most part, they just have to sign a form with their name, and that's it. it's really wonderful to sort of watch them take a big breath and relax during the course of the visit because i think what they find as they're here is that we do meet their needs. they get the tests done that they need. they get the medications that they need. they can't believe they're not going to have to go to a pharmacy and somehow come up with $60 or $100. it's interesting that many people try to use the clinic as an urgent care center. we have had examples of a man who was having a heart attack who drove by many major hospitals and did not stop, and was coming to us because he knew that we knew him very well. he's been here with us for many years and that he trusts us, and that we could help him. and so what we're able to do is stabilize our patients

if there's a case of emergency, and we call paramedics and then refer them to the hospitals for their care. last year, the clinic recorded more than 80,000 patient visits and filled more than 65,000 free prescriptions. no one paid a cent for the care they so badly needed. they frequently haven't had care in a long time. they've delayed going to the doctor. they've neglected themselves. they've put other things first like housing and feeding their children. and so they're quite sick, frequently, by the time we come here. and unfortunately that hasn't changed. we see a lot of people who are immigrants, and that has not really changed. and unfortunately we still see lots of people who are homeless. i think all that's really happened is that the numbers of people in need have increased. elizabeth benson forer: when i was here very early on i met a patient and i asked her, "tell me, how did you come to the clinic?"

and she said she had been a headhunter for a medical headhunting firm and she had decided to switch jobs. within her first month of work, her daughter fell at school, and broke her arm. she didn't have health insurance at the time. the daughter had a severe break and needed to be hospitalized. while she was doing her new job from the hospital room of her daughter, she was fired. so she went from making about $50,000 a year to nothing in seconds. at the point i met her, they were on the verge of being homeless, and she had developed some type of back problem and was having problems walking. she was delighted to come here because she said it was the first time she felt that someone really looked at her and said, "this is a person we can help." it's things like that that make you realize, this can be anybody in our society. people used to live in extended families, and when one person in a family had rough times, the rest of the family helped.

the one thing i've noticed over all these years is the difference between someone being homeless and not homeless is usually that the homeless person doesn't have any family to catch them when they fall, or they've burnt all their bridges with family, or their family's in a position where they can't help them. and then they end up utterly and totally alone. the clinic provides basic care, but not specialized care. for that they rely on the generosity of "volunteers." we have about 175 staff members, but the wonderful thing about this agency is that we've been able to secure a lot of volunteers. we have 2,600 volunteers working with us in a year, and 600 of them alone are doctors that are providing about 35,000 patient visits in a year. part of our comprehensiveness is through intent,

and part of it is serendipity, and that's good and bad. you know, when we see a need, we try to fill it. but because we frequently fill it with a volunteer, it's not always dependable. when i have a nephrologist who's volunteering, then we run nephrology clinic once a month. if the nephrologist moves out of town, we don't have nephrology clinic available here anymore. so then we will go out and look for someone to replace that physician. but for the patient's sake i wish we weren't so dependent on luck and serendipity and charity. i mean, i wish it was just a given that if they needed to see the nephrologist, they would get to see one. as the demand for their services is exploding, the staff is attempting to retain the personal service for which they are known. our fear is that we've lost that feeling of family-- the family clinic where everyone knew everyone, and we've gotten a little bit more anonymous. and we want patients to feel comfortable here.

we want them to know their physician. so our solution to that is to move to a team approach, that's sort of breaking down a large company, a large clinic, into multiple small clinics so that the patients interact with the same nurse every time, and they see one of three physicians instead one of 10, and they interact with the same case manager. so far, i think everyone likes it. for many patients, the case manager is the key to healthcare at the clinic itself, and points beyond. for your medications, make a left at the second window. the pharmacist will give you the instructions - on your medications, sir. - okay. thank you for waiting. susan fleischman: case managers are really the glue to the care that we give here. besides the fact that they sit and work with patients one-on-one sometimes for 15, 20, 30 minutes, they're the people that allow us to use all of the in-kind services that we use. so if the patient has multiple needs, you can imagine that they're going to go see two or three different doctors in the community.

they may have their blood sent to three different laboratories, and they may have radiologic studies at two different facilities. that's overwhelming, even if you have a car and a map. but if you don't have transportation, it's really overwhelming. the case managers actually make it happen. as we are talking about the medicines that they need to take or they need to go to a hospital for special tests, we're also asking them, "do you need food?" "do you need shelter?" the quality of care at the venice family clinic is often compared to that which a patient would receive in the private sector. susan fleischman: we may actually be a little slower here than physicians who are working in a capitated environment. our motivation is not so much to see a lot of patients because of the income, but we're sort of driven by the need. there's this constant sense that we're turning patients away, that if we went a little faster, we could see more people that day. so that tends to drive you to go a little faster.

on the other hand, the patients here are quite needy. so a five minute in-and-out really doesn't touch the surface. so we take as long as we need, you know, on the other hand, i'm sort of watching the clock and thinking, "who's outside who can't get seen if i go too slowly?" so the dynamics are a little bit different. the pride in the work they do is tempered by the fact that such a facility is needed at all. susan fleischman, m.d.: i so much wish that we didn't need to exist. so i'm always ambivalent about "oh, isn't it wonderful that we've grown, and isn't it wonderful that we offer the services that we do?" but it's really just a marker for the need in the community. and so it's actually very sad that we've had to grow to the extent that we have. and i wish people just got healthcare, as part of what you get when you live here in the united states, like you get public education. my long term vision would be to see a day when anybody could go to a doctor and just get care,

and the question wouldn't be, "what insurance do you have? what form do you have? how are you going to pay for this?" that there is a basic knowledge. i lived in england for a little bit. i got sick there. i went to the doctor. it cost me ten cents, and the ten cents was for the bottle for my medication. that was it. i know that england has a problem with their system, and they're working on it, but i think we need to really come up with something that works for everybody that's living in the country. and it's not a question of who's american and who's not. i was in england. i wasn't a citizen. it's a question of caring for people because they're here and they're here now, and they have a need. you never know why someone touches you more than someone else, but it does happen. and several months ago i saw an older homeless gentleman, and it was his first visit to the clinic. he was a very quiet man, well kempt, well dressed. we started to chat a little bit. and he had been sent here from a local hospital

where he'd been seen in the emergency room for atrial fibrillation, which is a fast heartbeat which can be life threatening. had been admitted to the hospital for several days, was discharged, and they suggested to him that he follow-up here. this gentleman was about 63, 64, was brand new to the streets. he was absolutely, utterly homeless which is unusual. most of the homeless patients we see are younger than that. so i asked him to tell me what his story was. he had lived and worked for the last 30 years in a bookstore. and as a favor, he slept upstairs. so he was kind of a quiet gentleman. he had no family, he didn't have a lot of friends, and the bookstore went bankrupt. he had no savings, so as soon as the bookstore closed its shop, he was out on the street. he was on the street for about 48 hours,

and i suspect on a stress-related basis, went into this horrible heart rhythm, had chest pain, couldn't breathe, fell down in the street, and someone called 911. he was taken to the hospital which is how he ended up here. so we helped him with his medical needs, but the bigger issue for this gentleman was you know, how was he-- brand new homeless, completely vulnerable, older, going to survive on the street? and he was not very many months away from collecting social security income and receiving medicare. and i remember i sort of jovially said, "well, the good news is, you're close to 65. those things will be available to you in a number of months." and he looked at me and he said, "i'll die before then."

"the human condition" is a 26 part series about health and wellness. for more information on this program and additional materials, call: or, visit us online at: [♪...] >> female announcer: some dreams

are universal... dreams that inspire us. multiple sclerosis is a devastating disease that changes lives forever. the national ms society does more for people with ms than any organization in the world... but we can't do it alone. to get involved, visit us online at nationalmssociety.org or call 1-800-fight ms. this is why we're here... because nobody dreams of having multiple sclerosis.